Problem/Conditions: Despite widespread availability of a safe and
effective
vaccine against tetanus, 124 cases of the disease were reported
during
1995-1997. Only 13% of patients reported having received a primary
series
of tetanus toxoid (TT) before disease onset. Of patients with known
illness
outcome, the case-fatality ratio was 11%.

Reporting Period Covered: 1995-1997.

Description of System: Physician-diagnosed cases of tetanus are
reported by
state and local health departments to CDC's National Notifiable
Diseases
Surveillance System. In addition, since 1965, supplemental clinical
and
epidemiologic information for cases has been provided to CDC's
National
Immunization Program.

Results: From 1995 through 1997, a total of 124 cases of tetanus
were
reported from 33 states and the District of Columbia, accounting
for an
average annual incidence of 0.15 cases per 1,000,000 population.
Sixty
percent of patients were aged 20-59 years; 35% were aged greater
than or
equal to 60 years; and 5% were aged less than 20 years, including
one case
of neonatal tetanus. For adults aged greater than or equal to 60
years, the
increased risk for tetanus was nearly sevenfold that for persons
aged 5-19
years and twofold that for persons aged 20-59 years. The
case-fatality
ratio varied from 2.3% for persons aged 20-39 years to 16% for
persons aged
40-59 years and to 18% for persons aged greater than or equal to 60
years.
Only 13% of patients reported having received a primary series of
TT before
disease onset. Previous vaccination status was directly related to
severity
of disease, with the case-fatality ratio ranging from 6% for
patients who
had received one to two doses to 15% for patients who were
unvaccinated. No
deaths occurred among the 16 patients who previously had received
three or
more doses. Tetanus occurred following an acute injury in 77% of
patients,
but only 41% sought medical care for their injury. All patients who
sought
care were eligible for TT as part of wound prophylaxis, but only
39%
received it. Tetanus in injecting-drug users (IDUs) with no known
acute
injury comprised 11% of all cases, compared with 3.6% during
1991-1994.
None of the IDU-associated tetanus cases occurred among persons who
were
known to have been vaccinated. Sixty-nine percent of IDU-associated
tetanus
cases were reported from California, and 77% of these cases
occurred in
heroin users.

Interpretation: Tetanus remains a severe disease that primarily
affects
unvaccinated or inadequately vaccinated persons. Adults aged
greater than
or equal to 60 years continue to be at highest risk for tetanus and
for
severe disease. However, the overall incidence of tetanus has
decreased
slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a
result
primarily of a decreased incidence among persons aged greater than
or equal
to 60 and less than 20 years.

Actions Taken: Tetanus is preventable through both routine
vaccination and
appropriate wound management. In addition to decennial booster
doses of
diphtheria and tetanus toxoids during adult life, the Advisory
Committee on
Immunization Practices (ACIP) recommends vaccination visits for
adolescents
at age 11-12 years and for adults at age 50 years to enable
health-care
providers to review vaccination histories and administer any needed
vaccine. Every contact with the health-care system, particularly
among
older adults and IDUs, should be used to review and update
vaccination
status as needed.

INTRODUCTION

The reported incidence of tetanus morbidity and mortality in
the
United States has declined substantially since the mid-1940s, when
tetanus
toxoid became universally available (1). This decline has resulted
from a)
widespread use of tetanus toxoid-containing vaccines (TT) for
vaccination
of infants and children (e.g., as diphtheria and tetanus toxoids
and
pertussis vaccine {DTP} or as diphtheria and tetanus toxoids for
adult use
{Td}), b) use of TT and tetanus immune globulin (TIG) for
postexposure
prophylaxis in wound treatment, and c) improved wound care
management. In
addition, increased rural to urban migration (2), with consequent
decreased
exposure to tetanus spores, may have contributed to the decline in
tetanus
mortality noted during the first half of the century.

Vaccination coverage with TT among school-aged children has
improved
substantially with the adoption and implementation of state
immunization
requirements. Forty-nine of the 50 states and the District of
Columbia have
passed legislation requiring that children be vaccinated for
tetanus before
admission to school (3), and greater than 96% of school-aged
children have
received three or more doses of DTP by the time they begin school
(4). In
addition, among children aged 19-35 months, national vaccination
coverage
with three or more doses of DTP has increased significantly (p less
than
0.05), from 83% in 1992 to 95% in 1996 (5).

National surveillance for tetanus is conducted to monitor the
epidemiology of the disease and to identify high-risk populations.
In this
report, we describe the epidemiology of tetanus in the United
States from
1995 through 1997 and update tetanus morbidity and mortality trends
from
1947 to 1997.

METHODS

Tetanus Surveillance

National tetanus surveillance relies on reporting of
physician-diagnosed cases to state and local health departments.
The
diagnosis of tetanus is based on the clinical judgment of the
attending
physician because a laboratory test for definitive diagnosis of
tetanus is
not routinely available. In 1990, the Council of State and
Territorial
Epidemiologists and CDC adopted the following clinical case
definition for
public health surveillance for tetanus: "Acute onset of hypertonia
and/or
painful muscular contractions (usually of the muscles of the jaw
and neck)
and generalized muscle spasms without other apparent medical cause
(as
reported by a health professional)" (6).

State health departments report cases of tetanus on a weekly
basis to
CDC's National Notifiable Diseases Surveillance System (NNDSS). CDC
publishes the number of tetanus cases reported by each state to
NNDSS on a
weekly basis and in an annual summary (1). In addition, since 1965,
state
health departments have reported supplemental clinical and
epidemiologic
information for cases to CDC's National Immunization Program. This
supplemental reporting system provides CDC with information about
the
clinical history, presence and nature of any associated risk
factors,
vaccination status of the patient, wound care, and clinical
management for
each tetanus case (7). A summary of this additional information is
published approximately every 2-4 years (8-12).

RESULTS

Long-Term Trends

During 1995-1997, a total of 124 tetanus cases with onset
during this
period (i.e., 40 * cases in 1995, 36 in 1996, and 48 in 1997) were
reported
to NNDSS. The annual average for this period was 41 cases, which is
the
lowest annual average ever reported since national tetanus
surveillance
began in 1947 (Figure_1) and is lower than the average of 50
cases
reported from 1991 through 1994 (12). The incidence rate of 0.15
cases per
million population represents a slight decline from the rate of 0.2
cases
per million population reported from 1987 through 1994 (8-12) and a
96%
decrease from the 3.9 cases per million population reported for
1947. The
overall case-fatality ratio also has declined, from 91% in 1947 to
24%
during 1989-1994 and to 11% during 1995-1997.

Epidemiology

At least one case of tetanus was reported by each of 33
states, the
District of Columbia, and New York City during 1995-1997
(Figure_2),
and tetanus cases were reported all 3 years by 10 states
(California,
Colorado, Florida, Illinois, Louisiana, Minnesota, New York,
Pennsylvania,
Tennessee, and Texas). Of the 17 states with no reported cases,
seven (41%)
were located in the Rocky Mountain and West North Central regions.
Tetanus
incidence in these regions has historically been low (8-12). An
additional
five states with no reported cases (29%) were located in New
England.

Data on age were reported for all 124 patients. Of these, 44
(35%)
were aged greater than or equal to 60 years; 74 (60%) were aged
20-59
years; and six (5%) were aged less than 20 years, including one
case of
neonatal tetanus and four patients aged 1-14 years (Figure_3).
In
contrast, during 1991-1994, 54% were aged greater than or equal to
60 years
(an annual average of 25 cases) (12), and 41% were aged 20-59
years. During
1995-1997, the average annual incidence among persons aged greater
than or
equal to 60 years was 0.33 cases per million population, a more
than
12-fold increased risk compared with that for persons aged 5-19
years
(0.026 cases per million population), and a nearly twofold
increased risk
compared with that for persons aged 20-59 years (0.17 cases per
million
population) (Figure_3).

Data on sex were reported for all 124 patients; data on race
and
ethnicity were reported for 120 (97%) of the 124 patients. Of the
124
cases, 74 (60%) were male. The female-to-male ratio among patients
aged
20-59 years was 0.42; among patients aged greater than or equal to
60
years, the ratio was 1.75. For persons aged 20-59 years, the
incidence
among males (0.24 cases per million population) was 2.4 times
greater than
that among females (0.10 cases per million population). For persons
aged
greater than or equal to 60 years, incidence among males (0.28
cases per
million population) was similar to that among females (0.37 cases
per
million population). Incidence among whites was 0.15 cases per
million
population; among Hispanics, 0.27; and among blacks, 0.09.

Supplemental clinical and epidemiologic information was
provided for
123 (99%) of the 124 reported tetanus cases. One case of neonatal
tetanus
was reported in an infant who was delivered in 1995 in a hospital
where
standard aseptic practices were used. The mother had immigrated
from Mexico
8 years before delivery and had previously received only one
tetanus
vaccination in Mexico at age 12 years. Since moving to the United
States in
1987, she had given birth to two other children in a hospital, and
the
index pregnancy included five routine visits for prenatal care
during the 6
weeks before delivery. The family's home in the United States was
near a
pasture where cattle grazed. The infant recovered fully after a
2-month
hospitalization (13).

The youngest non-neonatal tetanus case occurred in an
unvaccinated boy
aged 3-1/2 years who had been stung by an insect. Because of their
religious beliefs, his parents initially refused medical care for
the
tetanus and treated the child with herbal tea and carrot juice. The
child
had generalized tetanus that required mechanical ventilation; he
recovered
after a 24-day hospitalization.

Previous Vaccination Status

Sixteen (13%) of the 122 non-neonatal patients with
supplemental data
were reported to have received at least a primary series (i.e.,
three or
more doses) of TT before onset of illness (Table_1), including
two
(40%) of the five non-neonatal patients aged less than 20 years.
Three
(60%) of the non-neonatal patients aged less than 20 years were
unvaccinated because of their parents' religious objections. The
fourth
case occurred in a boy aged 14 years who was bitten by a dog and
who had
received his last dose 2 years previously. This patient did not
seek
medical care for his injury and was later hospitalized with tetanus
for 2
days. He did not require mechanical ventilation and subsequently
recovered.
The fifth case occurred in a boy aged 15 years who was in a moped
crash;
the interval since his last dose was 11 years. The patient sought
medical
attention and received TT within 6 hours of his injury; he was
hospitalized
4 days and recovered without sequelae.

Of the 14 (11%) patients aged greater than or equal to 20
years who
were known to have received a primary series, six reported receipt
of the
last booster dose less than or equal to 10 years before onset of
illness
and two within 5 years before onset of illness.

Case-Fatality Ratio

Fourteen deaths occurred among 122 patients with known
outcome,
representing a case-fatality ratio of 11%. All tetanus-related
deaths
occurred among patients aged greater than or equal to 25 years. The
case-fatality ratio varied from 2.3% among patients aged 20-39
years to 16%
among patients aged 40-59 years and to 18% among patients aged
greater than
or equal to 60 years. Previous vaccination status was directly
related to
disease severity: the case-fatality ratio ranged from 6% for
patients who
had received one to two doses of TT to 15% for patients who were
unvaccinated. No deaths occurred among the 16 patients who
previously had
received three or more doses (Table_1), and only one patient
required
mechanical ventilation. Of these 16 patients, nine had generalized
tetanus,
four had localized tetanus, and one had cephalic tetanus. For two
cases,
the type of tetanus was unknown.

Type of Injury, Wound Treatment, and Prophylaxis

An acute injury sustained before onset of illness was
identified for
93 (77%) of the 120 tetanus cases with known injury status. Of
these cases,
46 (49%) occurred after puncture wounds, the most frequent type of
injury.
Of the 33 patients for whom the circumstance of the puncture wound
was
known, 13 (39%) had stepped on a nail. Other puncture wounds
resulted from
self-performed body piercing (one case), self-performed tattooing
(one
case), animal bites, and splinters. The case associated with body
piercing
occurred in a woman aged 27 years who pierced her umbilicus at home
with a
sterile 16-gauge needle. The other most frequently reported types
of acute
injury were 20 (22%) lacerations and 11 (12%) abrasions. Nine (10%)
of the
93 patients with an acute injury also reported injecting-drug use
(IDU). An
additional three patients had an acute injury related to surgery
performed
4-8 days before onset of illness; none of these patients were known
to have
been vaccinated for tetanus. These patients included a woman aged
63 years
who underwent a hemorrhoidal banding procedure, a man aged 41 years
who had
an implant inserted in his back, and a man aged 32 years who had
knee
surgery. All three patients were administered TIG therapeutically
and
recovered.

The site of the antecedent acute injury was a lower extremity
in 43
(46%) patients, an upper extremity in 33 (35%) patients, and the
head or
trunk in 11 (12%) patients. The injury site was not specified for
six
patients. The environment in which the antecedent injury occurred
was
reported for 85 patients. Of these patients, 20 (24%) were injured
while at
home; 13 (15%) while indoors, other than at home; 33 (39%) while
performing
outdoor farming or gardening activities; and 19 (22%) while engaged
in
other outdoor activities. The median incubation period was 6 days
(range:
0-73 days) for the 92 non-neonatal cases with an acute injury for
which
dates of injury and illness onset were known. For 90 (98%) of these
cases,
the incubation period was less than or equal to 30 days.

Information regarding medical care was reported for 88
patients who
became ill with tetanus after sustaining an acute injury. Of these
patients, 36 (41%) obtained medical care for their injury, and all
were
eligible to receive Td prophylaxis for wound management. TT was
administered as prophylaxis to only 14 patients (i.e., 39% of those
who
obtained medical care), 10 (71%) of whom received toxoid within 24
hours
after the injury. The remaining 22 patients were eligible for Td
prophylaxis but did not receive it as recommended by the Advisory
Committee
on Immunization Practices (ACIP). Of the 13 (43%) patients who
sought
medical care and whose wounds were debrided, only three received
the TIG
indicated as part of wound prophylaxis.

Twenty-nine non-neonatal cases unrelated to acute injury were
associated with underlying medical conditions, including chronic
wounds or
IDU. Two patients had breast tissue necrosis secondary to breast
cancer.
Three patients had diabetes, two of whom were insulin-dependent.
Thirteen
(43%) of the patients without an acute injury were known to be IDUs
(one of
whom also had insulin-dependent diabetes), representing 11% of all
tetanus
cases. The median age of patients with IDU-associated tetanus was
43 years
(range: 24-60 years); 11 (85%) were male. Vaccination history was
known for
three (23%) of the 13 IDU-associated patients, all of whom were
unvaccinated. The overall case-fatality ratio among IDU-associated
cases
was 15%. Nine (69%) of the 13 IDU-associated cases were reported
from
California. Of these cases, eight (89%) were Hispanic, seven (78%)
were
male, and three (33%) were aged 20-29 years. Although information
on the
types of drugs used is not routinely collected on IDU-associated
tetanus
cases, seven of the patients with tetanus from California were
identified
as heroin users (14).

Clinical Features and Treatment

The type of tetanus was reported for 100 (82%) of the 123
cases with
supplemental information. Of these cases, 81 (81%) were
generalized; 13
(13%), localized; and six (6%), cephalic. Therapeutic TIG
administration
for treatment of clinical tetanus was reported for 108 (88%)
patients, and
the exact dosage of TIG was specified for 80 (74%) patients. The
median TIG
dosage used therapeutically was 3,000 IU; 75% of the patients
received
1,000-4,000 IU of TIG. The interval between onset of illness and
TIG
administration was known for 102 (94%) of the patients who received
TIG;
TIG was administered to 35 (34%) of these patients less than 24
hours after
onset of illness and to 40 (40%) patients 1-4 days after onset. The
case-fatality ratio for patients who received therapeutic treatment
within
24 hours was 9%, compared with 10% for those who received treatment
greater
than 1 day after onset of illness. Information about illness
outcome was
reported for 107 (99%) patients who received TIG; 11 (10%) of these
patients died. Two (20%) of the 10 patients who did not receive TIG
died.

Length of hospitalization was reported for 98 (79%) patients;
the
median duration was 11 days (range: 0-79 days). Of the 96 patients
for whom
the use of assisted ventilation was reported, 46 (48%) received
ventilation. Eighteen percent of those who required ventilation
died,
compared with 6% of those who did not require ventilation.

DISCUSSION

Tetanus remains a severe disease occurring primarily among
persons who
are unvaccinated or inadequately vaccinated. Adults aged greater
than or
equal to 60 years continue to be at highest risk for tetanus and
for severe
disease. However, the overall incidence of tetanus has decreased
slightly
since the late 1980s and early 1990s, from 0.20 to 0.15 cases per
million,
a result primarily of a decreased incidence among persons aged
greater than
or equal to 60 and less than 20 years. In addition, for the first
time
since 1973 (15), patients aged 20-59 years have accounted for a
greater
proportion of cases (60%) than those aged greater than or equal to
60
years, with most (52%) of these cases in the 20-49 year age group.
This
change in age distribution has resulted from both an increase in
the
average annual number of cases among persons aged 20-59 years and a
decrease in the average annual number of cases among persons aged
greater
than or equal to 60 and less than 20 years (12).

Older adults are at highest risk for tetanus because of the
low
prevalence of immunity to tetanus in this population. Data obtained
from a
national population-based serologic survey conducted during
1988-1991
indicate that the prevalence of immunity to tetanus in the United
States is
lower in older age groups, from greater than 80% among persons aged
6-39
years to 28% among persons aged greater than or equal to 70 years
(16). The
decreased incidence among older adults during the 1990s may be in
part
related to increases in tetanus vaccination among persons aged
greater than
or equal to 60 years. The National Health Interview Survey, a
national
probability sample, ascertained a moderate increase in tetanus
vaccination
rates among older adults; in 1991, 27% of persons aged greater than
or
equal to 65 years reported that they had received a tetanus
vaccination
during the preceding 10 years. By 1995, this figure had increased
to 36%
(CDC, unpublished data). Although this increase in tetanus
vaccination does
not entirely explain the twofold decreased incidence in adults aged
greater
than or equal to 70 years, it suggests increased compliance with
current
tetanus vaccination recommendations for adults (17). Nonetheless,
to
further reduce the tetanus burden among older adults, improved
compliance
with these recommendations is needed to increase population
immunity.

The disproportionate number of tetanus cases in the 20-59 year
age
group is in part related to an increased number of cases among
IDUs,
particularly among Hispanics in California. Among patients aged
20-59
years, IDUs comprised 27% of cases and 14% of cases with no acute
injury.
Overall, IDUs comprised 18% of all cases; IDUs with no acute injury
comprised 11% of all cases. In contrast, from 1982 through 1994,
the
overall proportion of IDU-associated cases ranged from 2.1% to 4.5%
(8-12) **. The increase in the number of IDU-associated tetanus
cases is
related to an increase in cases reported from California; although
California has reported most (59%) of these cases in the United
States
since 1987, the number of IDU-associated cases reported from
California has
increased steadily since the 1990s, particularly in recent years
(14). A
disproportionate number of IDU-associated cases was last observed
in the
United States among cases reported during 1970-1971 (18).

IDUs, particularly heroin users, have previously been reported
to be
at high risk for tetanus both in the United States and elsewhere
(19-24).
The high risk among IDUs is related to both increased exposure and
susceptibility, including: a) the high prevalence of abscesses,
which favor
anaerobic conditions for bacterial growth, secondary to nonsterile
injection practices (25); b) subcutaneous injection ("skin
popping")
(19,20,22); c) contamination of the drug supply (20,21); and d) low
prevalence of immunity (19,24). The increased number of cases among
Hispanic IDUs may be related to both low prevalence of immunity to
tetanus
and exposure to contaminated heroin. A national population-based
seroprevalence survey conducted during 1988-1991 identified ethnic
differences in tetanus immunity. Only 58% of Mexican-Americans (the
predominant Hispanic population in the Western region {26}) had
protective
levels of tetanus antibodies, compared with 73% of non-Hispanic
whites and
68% of non- Hispanic blacks (16).

Most of the heroin supplied to the Southwest is available in
the
resinous form called "black tar" (27,28); the use of black tar
heroin may
be increasing in this region (29). A recent increase in cases of
wound
botulism (an anaerobic bacterial infection caused by Clostridium
botulinum)
associated with injecting black tar heroin has also been reported
among
drug users in California (29). Whether the disproportionate number
of
IDU-associated cases from California is because of an increase in
black tar
heroin use remains unclear and requires further investigation (14).
Among
IDUs for whom drug cessation strategies have not been successful,
strategies to prevent cases of tetanus among IDUs, include a) use
of clean
needles and sterile injection technique (30) and b) assessment and
updating
of vaccination status as needed during every contact with the
medical-care
system. ACIP recognizes that IDUs are at increased risk for tetanus
and
recommends that they be kept up-to-date with Td vaccinations (31).

The case of neonatal tetanus reported in 1995 was the first
reported
since 1989 (32). Although nearly all tetanus cases in the United
States
occur in adults, most reported tetanus cases worldwide occur in
neonates,
with an estimated 490,000 deaths worldwide attributed to neonatal
tetanus
in 1994 (33). The goal of worldwide neonatal tetanus elimination
was
adopted by the World Health Assembly in 1989 (34). This goal has
been
defined as less than one case per 1,000 live births in the presence
of a
functional surveillance system. The key strategies are a)
achievement and
maintenance of high vaccination coverage levels among women of
childbearing
age in high-risk areas and b) promotion of clean delivery and
cord-care
practices (35). The two most recent neonatal tetanus cases in the
United
States occurred among infants born to immigrants in the United
States in
1989 (32) and 1995 (13). The elimination of neonatal tetanus in the
United
States can ultimately only be achieved through improved worldwide
coverage
with at least two doses of TT among girls and women of childbearing
age.

National health objectives for the year 2000 include a
disease-elimination objective of no tetanus cases among persons
aged less
than 25 years. Three of the 12 cases among persons aged less than
25 years
were among children who had received no vaccines because their
parents had
religious or philosophic objections to vaccination. Tetanus is not
a
communicable disease, and the organism is ubiquitous in the
environment;
unlike other vaccine-preventable diseases, there is no herd
immunity to
tetanus. As long as any child remains susceptible to tetanus, cases
of
tetanus among children in the United States can continue to occur.

The number of cases derived from passive reporting by
physicians to
local and state health departments underestimates the true
incidence of
tetanus in the United States. Completeness of reporting for tetanus
mortality has been estimated at 40%, while completeness of
reporting for
tetanus morbidity may be lower (36). Although tetanus mortality
reporting
is incomplete, reported tetanus deaths are representative of all
tetanus
deaths (36). Because fatal cases are more likely to be reported
than
nonfatal ones, possible changes in reporting practices do not
appear to
explain the decreased number of reported cases among older adults,
who are
more likely to have severe disease.

Tetanus remains a clinical diagnosis because confirmatory
laboratory
tests are not available for routine use. Isolation of the organism
from
wounds is neither sensitive nor specific: anaerobic cultures of
tissues or
aspirates usually are not positive, and the organism might be grown
from
wounds in the absence of clinical signs and symptoms of disease
(37-39).

Tetanus is preventable through both routine vaccination and
appropriate wound management. Vaccination with a primary series of
three
doses of TT-containing vaccine and booster doses of Td every 10
years are
highly effective in preventing tetanus (40). During 1995-1997, only
13% of
patients were known to have completed a primary series with TT
before onset
of tetanus, and only 47% of these had been vaccinated during the 10
years
preceding onset of tetanus. In addition, nearly two thirds of
patients who
sought medical care following their injury did not receive
prophylaxis as
recommended by ACIP (Table_2).

ACIP recommends that persons be routinely scheduled for a
vaccination
visit at age 11-12 years (41) and age 50 years (42). Such visits
enable
health-care providers to a) review the patient's vaccination
status, b)
administer Td as indicated, and c) determine whether a patient
needs other
vaccinations (e.g., influenza and pneumococcal vaccinations).
Because many
patients with tetanus did not have an acute injury and only 41% of
those
who did have an acute injury sought medical care, every contact
with the
health-care system, particularly among the elderly and IDUs, should
be used
to review and update vaccination status as needed.

Acknowledgments

The authors thank Evelyn L. Finch and Barry I. Sirotkin for data
management
and statistical support and Peter M. Strebel and Roland W. Sutter
(all four
with CDC's National Immunization Program, Atlanta, GA) for their
critical
review of the manuscript; Cynthia D. O'Malley (California
Department of
Health Services, Berkeley, CA) for her assistance with surveillance
data;
and all reporting state and local health departments for their
efforts in
conducting tetanus surveillance.

References

Taeuber IB. The changing distribution of the population of the
United
States in the Twentieth Century. In Research reports, Vol V,
Population
distribution and policy, Mazie SM, ed. Washington, DC: US
Bureau of the
Census, Commission on Population Growth and the American
Future, 1972.

Office of National Drug Control Policy. Pulse check: national
trends in
drug abuse. Washington, DC: Executive Office of the President,
Spring
1995.

Bureau of Justice Statistics. Drugs, crime, and the justice
system: a
national report from the Bureau of Justice Statistics.
Washington, DC:
US Department of Justice, Office of Justice Programs,
Government
Printing Office, December 1992; publication no. (NCJ)133652.

Table_2Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Summarized recommendations for the use of tetanus prophylaxis in routine
wound management -- Advisory Committee on Immunization Practices (ACIP), 1991 (17)
===================================================================================================
Clean, minor wounds All other wounds *
History of adsorbed ------------------- ------------------
tetanus toxoid Td + TIG & Td TIG
----------------------------------------------------------------
Unknown or <3 doses Yes No Yes Yes
>=3 doses @ No ** No No ++ No
----------------------------------------------------------------
* Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture
wounds; avulsions; and wounds resulting from missiles, crushing, burns, or frostbite.
+ For children aged <7 years the diphtheria and tetanus toxoids and acellular pertussis
vaccines (DTaP) or the diphtheria and tetanus toxoids and whole-cell pertussis vaccines
(DTP) -- or pediatric diphtheria and tetanus toxoids (DT), if pertussis vaccine is
contraindicated -- is preferred to tetanus toxoid (TT) alone. For persons aged >= 7 years, the
tetanus and diphtheria toxoids (Td) for adults is preferred to TT alone.
& TIG=tetanus immune globulin.
@ If only three doses of fluid toxoid have been received, a fourth dose of toxoid -- preferably
an adsorbed toxoid -- should be administered.
** Yes, if >10 years have elapsed since the last dose.
++ Yes, if >5 years have elapsed since the last dose. More frequent boosters are not needed
and can accentuate side effects.
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